Effect Measure is a forum for progressive public health discussion and argument as well as a source of public health information from around the web that interests the Editor(s)

Monday, May 09, 2005

Weighing in on obesity

There is a lot of handwringing in public health circles over the obesity debacle. The latest CDC article (Flegal KM, Graubard BI, Williamson D, et al. Excess deaths associated with underweight, overweight, and obesity. JAMA. 2005;293:1861-1867) essentially repudiates an earlier one (Moktad et al. that featured CDC Director Gerberding as a co-author; JAMA. 2004;291:1238-1245). It has not only confused people, but given them license to eat whatever they want (with a little help from their enemies; see the first of several good posts from Lindsay; and one from Effect Measure along the same lines). We are now probably further back then we were when the first CDC article came out in 2004 touting obesity as the leading cause of death in the US.

Let's get the facts out of the way first. Americans eat too much and much that they eat is unhealthy. The definition of an "epidemic" is a sudden increase in incidence beyond the expected. The Behavioral Risk Factor Surveillance Survey (BRFSS) found that the obesity rate (BMIs above 30, where the Flegal et al. paper found marked increased mortality) went from 11.6% in 1990 (measured in 45 states) to 21.1% in 2002 (measured in 54 states, DC and US possesions). By that definition, "obesity" was an epidemic.

Whose fault is this? The Right wants to make it an issue of personal responsibility and choice. The Left wants to make it a structural issue. I'm on the "structure" side. But we can't win that argument and we shouldn't be tempted to try. What's worse, the public health community wasn't clear what it thought, addressing ordinary people and trying to convince them to eat a better diet. Public health essentially bought into a personal choice perspective.

The reason we can't win the structure argument is that most people--including those that espouse it--aren't completely solid themselves about it. I'd be willing to bet not a few were inwardly relieved and relaxed their diets as well. This isn't that surprising. How we think about things is strongly conditioned by our personal experience. When we were hunter gatherers we had no real choice about food; we ate what was edible and were able to catch or find, or later what we were able to grow for ourselves. But in today's world, where others produce our food in a competitive market, choice is at the center of eating. Our internal and largely unconscious experience is that we do get to choose what we eat. That sense may be largely illusory, but it is a powerful illusion. The public health campaign was directed at that experience: we should choose something different (healthier, purer, leaner, smaller). It didn't take into account that the fact that our choices are channeled, restricted and manipulated is not part of our conscious experience. As Lakoff and other cognitive scientists have emphasized, the facts are rarely enough to overcome unconscious inferences based on experience.

As long as public health confined itself to personal choice it was allowed to wage a "campaign against obesity." When it attacked the structure directly in the tort system or by applying pressure to schools to get junk food out of the vending machines, the Right took action, effortlessly identifying public health initiatives (occupational health and safety, for example) with "public health nannyism." It was a political bonanza. What made it so easy for them was the way their version fits so nicely and comfortably with ordinary (internal and unconscious) experience, while our story requires conscious processing, argument and some political "buy-in." This was a very, very tough game to win, and in today's media climate not possible. We should have foreseen it.

So how do we pick up the pieces? We should focus on aspects of the food supply where there demonstrably is no choice. Some possibilities: the idea of "chemical trespass" associated with involuntary exposure to food additives, pesticide residues and environmental contaminants (like the flame retardant polybrominated diphenyl ethers [PBDEs], the teflon feedstock chemicals perfluorooctanoic acids [PFOA], the plastic components bisphenol A and phthalates, etc.). Ordinary people don't know they are now carrying around substantial body burdens of these chemicals and don't like it when they find out. They immediately identify it as a "structural" issue, not a "choice" issue. There is a great deal of opportunity here to focus attention to agribusiness and the failing family farm and good groups working on it. We can bring in agribusiness's role as risk factors in obesity, attacking inadequate labeling laws (the "Right to Know" touches a core value and is a powerful lever we should use more), juices that have no juice in them or blueberry muffins that have no blueberries, trans fatty acids that aren't there because consumers want them but because it makes it easier for food processors. People would not willingly choose these things. We can make it work for us. People are forced to choose them by a structure beyond their control. Indeed, portraying a forced choice as the choice of a free subject is precisely the ideological message the Right wishes to reinforce.

The bottom line is we can't win on obesity or any food issue if we portray it as a problem of "wrong choices." Even those who don't espouse that view went along with it because it seemed like it got us to a healthier place. It was a trap. And we fell into it.